A cluster randomised controlled trial to evaluate the effectiveness of fluoride varnish as a public health measure to reduce caries in children.

This cluster randomised controlled study assessed the effectiveness of twice-yearly applications of fluoride varnish as a public health measure to reduce dental caries in children living in relatively deprived communities. The test (n = 334) and control (n = 330) children in 2 school years (unit of randomisation) attended 24 state primary schools and were 6-8 years of age at the start. Good baseline balance was found. Duraphat varnish was applied at school on 5 occasions over 26 months, by dental therapists. A combined visual and fibre-optic transillumination examination included all surfaces of primary and first permanent molars at baseline and after 26 months for small and large enamel and dentine lesions. At the final examination the only statistically significant difference was in the caries increment for small enamel lesions in the primary dentition, with the test children having fewer lesions. This study failed to demonstrate that the twice-yearly application of fluoride varnish provided at school reduced dental caries in children living in this community. The low level of response and a lower than expected caries increment had a major impact on the effectiveness of the intervention, since the children who participated were least likely to have benefited from the programme, whereas those who might have benefited did not consent.

Challenges associated with the evaluation of a dental health promotion programme in a deprived urban area.

OBJECTIVE: This paper reports the results of a community trial to measure the clinical impact of a linked series of interventions on Early Childhood Caries (ECC) and general caries levels among five-year-old children. It exemplifies the problems of undertaking population based interventions in deprived communities. RESEARCH DESIGN: Two health districts (Primary Care Groups) were matched for dental disease levels and socio-demographic factors. One was randomly allocated to be the active intervention PCG, the other the comparison PCG. Children in the active PCG received a series of interventions to support positive dental health behaviour from the age of 8 to 32 months. Clinical examinations were undertaken on a cohort of 5-year-old children in both active and comparison PCGs. SETTING: In the active PCG, children who attended designated clinics for their 8-month developmental checks and/or MMR inoculations at 12 to 15 months, were given gift bags, the first contained a trainer cup, the second fluoride toothpaste (1450 ppm F) and toothbrush. Parents were also given written, pictorial and verbal advice on oral care. Further supplies of toothpaste and brushes were posted to the children's homes at 20, 26 and 32 months. When five years of age children in the two PCGs were examined in school. OUTCOME MEASURES: Severity and prevalence of ECC and general caries. Levels of participation. RESULTS: Among participants in the active PCG the prevalence of ECC, general caries and extraction experience and mean dmft (20%: 54%: 3%: 2.2) were lower than in 'participants' in the comparison area (32%: 64%: 12%: 3.7). All differences were statistically significant. When all children (participants and non-participants) in the two PCGs were compared, the differences were much reduced (30%: 63%: 6%: 3.1 vs. 32%: 64%: 12%: 3.6). A higher proportion of children in the active PCG area (47%) were found not to have participated in the interventions, when compared to 21% in the comparison area. Disease levels in the non-participants in the active PCG were particularly high. The impact of participation bias, changes in baseline balance, population mobility and alternative study design on outcomes are explored. CONCLUSION: The impact of non-participation in a deprived, urban conurbation with high levels of population mobility are sufficient to dilute the impact of a health intervention such that few benefits are discernible at a population level.

A staged intervention dental health promotion programme to reduce early childhood caries.

OBJECTIVE: This paper reports the results of a community trial to assess the effects of a multi-stage dental health promotion programme in reducing Early Childhood Caries (ECC). RESEARCH DESIGN: Two health districts (Primary Care Groups) were matched for dental disease levels and socio-demographic factors. One was randomly allocated to be the test Primary Care Group (PCG), the other the control PCG. Children in the test PCG received a series of interventions to support positive dental health behaviour from the age of 8 to 32 months. Interviews were conducted with parents of children aged 21 months and clinical examinations were undertaken on a larger cohort of children aged 3-4 years in test and control PCGs. SETTING: The interventions were gift bags containing a trainer cup, toothpaste containing 1,450 ppm F and toothbrush, and advice given to the children's parents on attendance at designated clinics and medical practices and further paste and brushes posted to the children's homes. Parents were interviewed on the telephone. Examinations took place at Children's Centres and nursery departments attached to primary schools. OUTCOME MEASURES: Severity and prevalence of ECC and general caries and proportion of parents reporting adopting dentally healthy behaviours. RESULTS: In the test PCG the prevalence of ECC in children who had received the interventions was 16.6% compared with 23.5% of children in the control area, a reduction of 29% (p=0.003). The mean dmft (1.17) and prevalence of general caries experience (28.7%) in the test children were also significantly lower than for children in the control PCG (1.72: 39.2%) (p=0.001). Analysis from a community perspective, which included data from all children examined in both areas, showed the prevalence of ECC in the test and control PCGs was 21.3% and 22.8% respectively and the mean dmft 1.47 and 1.72. The proportion with general caries experience remained statistically significant in favour of the test area 33.8% vs 39.9% (p=0.01). Parents in the test PCG were more likely to report cessation of bottle use (33% vs 18%), use of sugar-free drinks (49% vs 24%), commencement of brushing before first birthday (45% vs 27%) and twice daily brushing (52% vs 34%). CONCLUSION: The parents who received this multi-stage intervention were more likely to report adoption of three positive oral health behaviours; using a trainer cup from one year of age, using safe drinks and brushing twice daily with a fluoride toothpaste. The programme failed to reduce the prevalence of ECC in the community but the prevalence of ECC and general caries experience among the children who participated was less than among children in the control PCG.

Developing dental education in primary care: the student perspective.

A pilot outreach course in restorative dentistry based in community clinics began in 2001. As part of the evaluation, 48 fourth year students completed a questionnaire about their opinions of the new course, and about restorative dentistry clinics in the dental hospital. Time management was the most frequently mentioned gain from outreach. In relation to the dental school, students most often saw the specialised teaching staff as a gain. Outreach was equally or more important for students' confidence in clinical diagnosis of dental caries, treatment planning, direct restorations, communicating with patients, and managing patients, time, and resources. The dental hospital was equally or more important for their confidence in the diagnosis of periodontal disease, root planing, crowns, bridges, dentures, and communicating effectively with laboratory staff. Patients in outreach were seen as different from those at the dental hospital because they were unselected, and had different treatment needs. Meeting course requirements was the most frequent concern about outreach. In relation to the dental hospital, students were most often concerned about the quality of teaching and support available. Outreach and the dental hospital provided complementary experiences and the new course met its educational objectives.

The power of children over adults when obtaining sweet snacks.

BACKGROUND: There is evidence to suggest that the family is becoming a more democratic unit and that children are spending more on sweet snack items than ever before. A study was thus undertaken to investigate the influence of children on parental decision-making in relation to the use of sugary snacks. METHODS: A cross sectional interview study; children aged 7-8 years from 20 inner-city Manchester primary schools were asked about their sweet eating, their pocket money and their perceived levels of influence or autonomy within the household. The parents of these children were also asked to fill in a questionnaire that mirrored the children's questions. RESULTS: There was a moderate but significant correlation between the opinion of the parents and that of the children on the extent of influence (Pearson coefficient r = 0.25, P = 0.001). When the adults (n = 181) were split into age groups, or= 36 years (n = 87), the study showed that the older the adult, the less the child seemed to get his or her own way. Spearman's rho = 0.16, P = 0.03 (children's view) and rho = 0.17, P = 0.02 (adult's view). The dominant factors were related to money in the children's opinion, although the adults' data suggested that older mothers (>or= 36 years) may be trying to limit their children's access to sweet snacks. CONCLUSIONS: Adults' efforts to limit their children's intake of sweet snacks and drinks are being undermined by earlier and earlier influences in the child's life and by access to money, which allows the child to out-manoeuvre his or her parents. This is compounded by the provision of additional income, mostly from grandparents.

Caries among 3-year-olds in greater Manchester.

OBJECTIVE: To measure the prevalence of caries, including nursing caries, amongst 3-year-old children in three districts of Greater Manchester in the North West of England. DESIGN: A cross-sectional survey of 762 randomly selected 3-year-old children using the dmft and dmfs indices. Three definitions of nursing caries were used in order to assess the varying prevalence of the disease according to which definition was applied. SUBJECTS: Children, aged 36-48 months, attending day nurseries, play groups and nurseries attached to primary schools were examined by three trained examiners under standardised conditions in three health districts in Greater Manchester. A random selection process was used to produce a quota sample to reflect the balance of childcare provision in each district. RESULTS: The overall proportion of children affected by general caries was 32%. The mean dmft score was 1.4 (sd = 2.8) and the mean dmfs was 2.8 (sd = 7.3). There were significant differences across the three districts. The prevalence of nursing caries varied widely when differing definitions of types were applied; 1.6% of the children had nursing caries according to the narrow definition, 7.2% showed the wider definition type and 9.8% had nursing caries of the broadest definition. In total 19% of children had caries which affected their upper incisors. Children of Asian origin had the highest levels of nursing and overall caries. CONCLUSIONS: Caries is a widespread problem in some very young children in the districts involved. Caries of upper anterior teeth contributes significantly to the overall level of caries in each of the localities in question. The prevalence of nursing caries is highly dependent on the case definition used.

The effects of different conventions regarding missing primary incisors in epidemiological studies.

OBJECTIVE: To assess the effects of two different conventions regarding the scoring of missing primary incisors in epidemiological studies. DESIGN: During 1995/96 a sample of 5-year-old children was examined as part of the national programme of surveys coordinated by the British Association for the Study of Community Dentistry. The fate of missing incisors was recorded according to two conventions and the resulting mean dmfts and components compared. SUBJECTS: Eight hundred and twenty-six randomly sampled 5-year-old children were examined by two trained and calibrated examiners under standardised conditions in their primary schools in North, Central and South Manchester. RESULTS: The overall mean dmft was 3.40 under the new convention and 3.60 with the old, a difference of 5.6%. The mean mt was depressed by 23% from 0.86 to 0.66 under the new convention. The differential between old and new conventions increased with dmft. The district with the highest mean dmft was affected most by the application of the new convention; the mean dmft was depressed by 8.5% from 4.33 to 3.96 and the mean mt was depressed by 32% from 1.17 to 0.80. All differences were significant (P < 0.01). CONCLUSION: A change in convention affected the results to varying degrees depending on the disease level of the population group being surveyed.